Form 433-F Internal Revenue Service ... - IRS tax forms

1 form 433-F (Rev. 6-2010) Department of the Treasury Internal Revenue Service Collection Information Statement Name(s) and Address If address provi ded above is different than last return filed please check here. County of Residence Your Social Security Number or Individual Taxpayer Identification Number Your Spouse s Social Security Number or Individual Taxpayer Identification Number Your Telephone Numbers Home: ( ) Work: ( ) Cell: ( ) Spouse s Telephone Numbers Home: ( )Work: ( ) Cell: ( ) A. ACCOUNTS / LINES OF CREDIT (including Banking Institutions, Checking and Savings accounts, Credit Unions, Certificates of Deposit, Individual Retirement Accounts (IRAs), Keogh Plans, Simplified Employee Pensions, 401(k) Plans, Profit Sharing Plans, Mutual Funds and Stock Br okerage Accounts) Name and Address of Institution Type of Account Current Balance / Value Total number of dependents you will be claiming on next year s tax return Over 65 Under 65 Total number of dep endents you claimed on last year s tax return Over 65 Under 65 B.

2 REAL ESTATE (home, vacation property, timeshares and other real estate) County / Description Monthly Payment(s) Financing Current Value Balance Owed Equity Primary Residence Other Year Purchased Purchase Price Year Refinanced Refinance Amount Primary Residence Other Year Purchased Purchase Price Year Refinanced Refinance Amount Primary Residence Other Year Purchased Purchase Price Year Refinanced Refinance Amount C. OTHER ASSETS (cars, boats, recreational vehicles, whole life policies, etc.) Description Monthly Payment Year Purchased Final Payment (mo / yr) Current Value Balance Owed Equity / / / / / / / Catalog 62053J TURN PAGE TO CONTINUE form 433-F (Rev. 6-2010) D. CREDIT CARDS (V isa, MasterCard, American Express, Department Stores, etc.) Type Credit Limit Balance Owed Minimum Monthly Payment E. WAGE INFORMATION (If you have more than one employer, include the information on another sheet of paper.) Your current Employer (name and address) How often are you paid?

3 (Check one) Weekly Bi weekly Semi-monthly Monthly Gross per pay period Taxes per pay period (Fed) (State) (Local) How long at current employer Date of Birth Total Income from Last Year s 1040 Tax Return Spouse s current Employer (name and address) How often are you paid? (Check one) Weekly Bi weekly Semi-monthly Monthly Gross per pay period Taxes per pay period (Fed) (State) (Local) How long at current employer Date of Birth Total Income from Last Year s 1040 Tax Return F. NON-WAGE HOUSEHOLD INCOME (List monthly amounts. For Self-Employment and Rental Income, list the monthly amount received after expenses or taxes.) Alimony Income: Child Support Income: Net Self Employment Income: Net Rental Income: Unemployment Income: Pension Income: Interest Income: Social Security Income: Other: G. MONTHLY NECESSARY LIVING EXPENSES (List monthly amounts. For expenses paid other than monthly, see instructions.) 1. Food / Pers onal Care Food: Housekeeping Supplies: Clothing and Clothing Services: Personal Care Products & Services: Misc.

4 (Cable, Internet, etc.)*: Tota l: 2. Transportation Gas/Insurance/Licenses/Parking/Maintenan ce etc.: Public Transportation: 3. Housing & Utilities Rent: Electric, Oil/Gas, Water/Trash: Telephone and/or Cell Phone: Real Estate Taxes and Insurance: (i f not included in B above) Total: 4. Medical Health Insurance:Out of Pocket Health Care Expenses: 5. Other Child / Dependent Care:Estimated Tax Payments:Term Life Insurance:Retirement (Employer Required):Retirement (Voluntary): Court Ordered Payments: Pr ofit and Loss Statement: See the instructions for detailed information on how to complete the Monthly Necessary Living Expenses. IRS st andard amounts are found on the internet at ht ,,id=96543, If you are required to send supporting documentation, please send copies and not the original documents. H. ADDITIONAL INFORMATION 1. The IRS may establish a payment agreement for you based on the financial data you provided. 2. We cannot consider an installment agreement unless all returns have been filed.

5 At tach a signed copy of ALL unfiled return(s). 3. Proposed Monthly Installment Agreement Payment Amount: 4. Proposed Monthly Payment Date: 5. Down Payment Amount: Under penalty of perjury, I declare to the best of my knowledge and belief this statement of assets, liabilities and other information is true, correct and complete. Your Signature Spouse s Signature Date Catalog 62053J form 433-F (Rev. 6-2010) Instructions Complete all the blocks. Write N/A (Not Applicable) for those which don t apply to you. We need you to complete the form so we can establish the best method for you to pay the amount due. If any section is too small for the information you need to supply, please use a separate sheet. Failure to complete the form or provide copies (not originals) of required attachments (as stated below) may result in a delay in resolving your account. We may also require you to submit financial substantiation after our financial analysis is complete. Section A Accounts / Lines of Credit List all accounts, even if they currently have no balance.

6 However, do not enter bank loans in this section. Section B Real Estate List all real estate you own or are purchasing. This listing should include your home and any other real estate you own. Include the county and description, the year(s) and amount(s) of purchase and/or refinancing, the current market value and the amount you owe. To determine equity, subtract the amount owed from its current market value. Section C Other Assets List all cars, boats, recreational vehicles, whole life policies, or other assets that you own. If a vehicle is leased, write lease in the year purchased column. To determine equity, subtract the amount owed from its current market value. Section D Credit Cards List all credit cards and lines of credit, even if there is no balance owed. Section E Wage I nformation Provide the name and address of employers for you and your spouse. Include both spouses income, even if the tax liability is not the result of a jointly filed return.

7 Check the appropriate box indicating how you are paid. Year to Date Income includes all income, without deductions, for you and your spouse. Include all wage income from all employers since January of the current year. Last years gross income should be recorded from last years filed return. Section F Non-Wage Household Income Enter monthly amounts for all sources of household income. For any income not received monthly, calculate the monthly amount as follows: If received quarterly - divide by three. If received weekly - multiply by If received biweekly - multiply by Net Self-Employment Income is the amount you earn after you pay ordi nary and necessary monthly business expenses. This figure should relate to the yearly net profit from Schedule C on your form 1040 or your current year profit and loss statement, but should not include depreciation expenses. If your net income is less than the previous year, attach an explanation. If net income is a loss, enter 0.

8 Net Rental Income is the amount you earn after you pay ordinary and necessary monthly rental expenses. This figure should relate to the amount reported on Schedule E of your form 1040 (do not include depreciation expenses). If net rental income is loss, enter 0 . Section G Monthly Necessary Living Expenses Expenses that do not provide for the health and welfare of youor your family or for the production of income are generallynot consi dered necessary. These may include tuition for private schools, public or private college expenses, charitable contributions, voluntary retirement contributions and payments to unsecured monthly amounts for expenses. For any expenses not paid monthly, calculate the monthly amount as follows: If paid quarterly - divide by three. If paid weekly - multiply by 4. 3. If paid biweekly - multiply by expenses claimed in boxes 1 and 4 you may either use the total amounts shown on the IRS websit e at ht ,,id=96543,00. html.

9 Substantiation may be required once the financial analysis is completed. If you are currently paying higher expenses you may enter that amount,but you are also required to submit supporting documentationwith this form , which show payments being boxes 2 and 3 you must enter only the amount you actuallyspend on these expenses. If your total amount is higher than theamount shown on the IRS website shown above, you areREQUIRED to submit supporting documentation when submitting this form , such as copies of cancelled checks etc. which show payments being expenses claimed in box 5 REQUIRE supporting documentation when submitting this form . This includes copies of cancelled checks, pay stubs etc. that indicate payments are being made. For any court ordered payments you MUST submit a copy of thecourt order portion that shows the amount you are ordered to payand the signatures. If you do not have access to the IRS websit e, it emize your actual expenses and we will ask you for additional proof, if -Do not enter mortgage payment here.

10 Medical -Enter only ongoing medical expenses. Do not include a one time only medical expense. Out-of-Pocket health care expenses include: Medical services Prescription drugs Medical supplies, including eyeglasses and contact lenses. Child / Dependent Care -Enter the monthly amount you pay forthe care of dependents that can be claimed on your form 1040. Estimated Tax Payments -Calculate the monthly amount youpay for estimated taxes by dividing the quarterly amount due onyour form 1040ES by Insurance -Enter the amount you pay for term lifeinsurance only. Whole l ife insurance has cash value and shouldbe listed in Section H Additional Information 1. The IRS will review your financial information and may establish a payment agreement for Attach signed unfiled returns to this form for Propose a payment amount to be paid: In 60-120 days or monthly payments in 60 months 4. Show the date you will make your payment each dates are from the 1st -28th of the Show the maximum down payment you can make to lower the balance due.